4 OSCE in intensive care medicine (jul 1, 2015) (1910079235) (tfm publishing)

Intensive care exams across the world are now incorporating this form of examination as part of the assessment process.. Take for example the Fellowship of the Faculty of Intensive Care

or by any means, electronic, digital, mechanical, photocopying, recording or otherwise, without the prior written permission of the publisher.

Neither the authors nor the publisher can accept responsibility for any injury or damage to persons or property occasioned through the implementation of any ideas or use of any product described herein Neither can they accept any responsibility for errors, omissions or misrepresentations, howsoever caused.

Whilst every care is taken by the authors and the publisher to ensure that all information and data in this book are as accurate as possible at the time of going to press, it is recommended that readers seek independent verification of advice on drug or other product usage, surgical techniques and clinical processes prior to their use.

The authors and publisher gratefully acknowledge the permission granted to reproduce the copyright material where applicable in this book Every effort has been made to trace copyright holders and to obtain their permission for the use of copyright material The publisher apologizes for any errors or omissions and would be grateful if notified of any corrections that should be incorporated in future reprints or editions of this book.

Printed by Cambrian Printers, Llanbadarn Road, Aberystwyth, Ceredigion, SY23 3TN

Tel: +44 (0)1970 627111; Web site: www.cambrian-printers.co.uk

Preface

Abbreviations

Interpreting a standard electrocardiogram (ECG) Acknowledgements

Dermatology — toxic epidermal necrolysis

Viral haemorrhagic fever — Ebola

Index

Objective Structured Clinical Examinations (OSCEs) in medicine are not a new phenomenon Intensive care exams across the world are now incorporating this form of examination as part

of the assessment process Take for example the Fellowship of the Faculty of Intensive Care Medicine (FFICM) examination in the United Kingdom (UK) which now includes OSCEs; thus, they are gaining further importance.

There are a number of intensive care medicine (ICM) textbooks available, but there are very few resources specifically aimed at the practice of OSCEs in ICM This book is not designed to

be a textbook; rather, it has been specifically designed to implement the rehearsal of OSCEs Much like a driving test there are certain things in the OSCEs that must be said to score that ever precious mark, even if it is stating the absolute obvious, for example:

Depending on the exam that you will sit, a fair proportion of questions will require answers in the form of lists (e.g list of tests you would order) In our experience this often leads to the examiner repeating the phrase “anything else?”! Try not to get thrown by this; you may have given an excellent answer but there is still a further mark for the one thing you didn’t mention and the examiner is trying to give you the opportunity to score that final mark! No matter how good your knowledge is, everyone forgets something in the heat of the exam! The OSCE answers and narratives in the book have been purposely arranged as bulleted lists timed for 6- minute stations This is because every station in an OSCE exam has listed scoring marks which are available in that finite time of 6 minutes With practice, your ‘OSCE mindset’ can be arranged so as to score marks in a systematic and organised, yet swift, manner For example,

Scoring systems have come up in past OSCE exams, hence many of the important ones have been incorporated into the chapters.

Remember that if you are sitting an exam with a viva element, there is the possibility of topic cross-over from the OSCE to the viva and vice versa To that aim, when using this book, it is worth trying to outline how you would answer the OSCE topic were you given it in a viva setting.

Simulation stations can form a station in ICM OSCEs We have made a conscious decision not to include them in the OSCE sets presented here, as high-fidelity simulation is very difficult

to emulate through a book Instead we have provided additional stations which could well form the basis of a simulation station.

We have included ‘Top Tip’ boxes to provide clues as to what the examiners are looking for and what they are expecting from your answers These tips have been assembled from the principal knowledge and experience of candidates who have undertaken ICM exams, hence they are well worth noting.

You will be examined in at least one of the so-called ‘professionalism’ stations, colloquially referred to as ‘communication skills’ stations, during the examination Commonly, these involve the use of actors, rather than patients, and you need to develop a strategy for dealing with the

‘method’ actor who takes their role too seriously Colleagues of ours have often expressed frustration when the ‘daughter’ of the simulated patient spent so much time crying that it proved very difficult to progress with the station Unfortunately, we have no magic formula for this occurrence, but highlighting the possibility of it happening will give you an opportunity to try to work out a strategy to deal with this The professionalism stations we have included in this book

do often read a little like a list; unfortunately, we can’t find any other way of introducing these types of topics You will need to rely on your ‘sparring partner’ to embellish these stations into something that resembles the OSCE station The station gives you the topic and a standard marking scheme but you will need a colleague to role play the actor’s part.

It is not uncommon for the same or similar topics to come up in the same exam, especially if they are deemed important, though as question banks increase in size this is less of an issue If

it does happen make sure you listen in case the focus of the question is different, and be thankful.

There are a number of more ‘formulaic’ stations and we have attempted to provide a system

to answer these The most common of these is the dreaded electrocardiogram (ECG) station Our advice would be to decide on your system of interpreting and presenting an ECG (we’ve outlined one very simple method in the book) Even if you have no idea what the ECG shows, you will be at least scoring marks as you go through it systematically When presented with the next ECG do the same; the examiner will most likely tell you if they do not want you to do this again, in which case if you don’t know the diagnosis you will struggle In our conversations with examiners, there are often marks for this systematic approach, so don’t miss out.

This is unlikely to be the first OSCE that you have sat in your medical career, so remember that all the rules you learnt at medical school still apply If you have a bad station, forget it and move on If you don’t know the answer to a question and the examiner is failing to move on then tell them! Most stations are designed to allow you to score marks, even if you fail to score the mark for the diagnosis.

Whilst both authors have been through the UK intensive care training programme, we have tried hard to minimise any possible bias towards examinations in the UK and Europe, in order to achieve a more global appeal Thus, the book is relevant for any ICM examination that contains

an OSCE element For those of you taking European-based exams, we have had contact with examiners for the European Diploma in Intensive Care Medicine (EDIC), as well as the newly created Fellowship of the Faculty of Intensive Care Medicine (FFICM) in the UK Many of these stations are based on real topics which have come up in both of these two examinations over the last few years; however, we have been careful to try and remove any European eccentricities, especially with respect to acronyms! As such we are confident that this book will prove an excellent training tool for any ICM exam which employs the OSCE format.

We wish you the best of luck with the exam you are about to take and look forward to seeing well-thumbed copies of this book on the nurses’ station in intensive care units (ICUs) across the country! We want the book to be a resource for colleagues to hone their skills for an OSCE format The book should be the perfect way of packing in 10 minutes of OSCE revision before the next ICU ward round starts!

Jeyasankar Jeyanathan BMedSci (Hons) MBBS DMCC PgCert (Med Sim) FRCA FFICM

Daniel Owens BSc (Hons) MBBS PgCert (Med Ed) FRCA FFICM

Intensive Care Unit, St George’s Hospital, London, UK

TEG® Thromboelastography

TEN Toxic epidermal necrolysis

TLS Tumour lysis syndrome

TOE Transoesophageal echocardiogramTRALI Transfusion-related acute lung injury

TTE Transthoracic echocardiography

TTP Thrombotic thrombocytopaenic purpuraU&Es Urea and electrolytes

Figure 4.3 http://www.lifeinthefastlane.com.

Figure 4.6. © C.R Bard Inc., 2015.

To the many teachers who took the time to teach and guide

us — thank you very much We hope that we too can contribute to this crucial continuation in medical education and training.

To our beautiful and beloved families, this book is testament to their tireless support, patience and love We dedicate this book to you.

Jeyasankar and Daniel

is a 45-year-old man admitted with pancreatitis 3 days ago He was

intubated on admission and his oxygen requirements have been increasing

• Microbiological samples, e.g sputum/broncho-alveolar lavage

outcome in severe ARDS cases:

• Prone positioning of the patient There was an improved mortality in severe

ARDS as recently shown in the PROSEVA trial 2

•

Muscle relaxation or paralysis The ACURASYS trial found an improvement inmortality with the early implementation of a cisatracurium infusion in cases ofsevere ARDS 3

• Extracorporeal membrane oxygenation (ECMO) The CESAR trial

demonstrated an improvement in oxygenation in patients with severe ARDS 4

T ip

The OSCE exam will often ask for a ‘list’ of answers; for example, please list some causes, differential diagnoses, specific investigations, etc It is important to recognise that time is a precious commodity and that the list needs to be produced in a succinct and swift manner In order to help with this it is well worth having a system to organise your answer and in the days approaching the exam to practice these systems in producing answers For example, in the question above on listing some differential diagnoses for the CXR, a simple system could be utilising the classic surgical sieve, ‘VITAMIN C’, or using the body systems to list potential causes So in this example the causes for this CXR could be organised as such:

– infective causes subclassified as bacterial, viral, protozoal

or fungal In this case many organisms could have precipitated such a chest radiograph;

– inflammatory causes — ARDS.

• N eoplastic.

• C ongenital.

Peek GJ, Clemens F, Elbourne D, et al CESAR: Conventional Ventilatory

Support vs Extracorporeal Membrane Oxygenation for Severe Adult

Respiratory Failure BMC Health Services Research 2006; 6: 163.

5) What are some of the management options or strategies that could be

employed for this patient to improve cardiac output?

3 marks (1 mark for each correct stem)

Chamos C, Vele L, Hamilton M, Cecconi M Less invasive methods of

advanced hemodynamic monitoring: principles, devices, and their role in the

perioperative hemodynamic optimization Perioper Med 2013; 2: 19.

This OSCE and mark sheet follows the National Tracheostomy Safety

Project guidelines, of which the key algorithms are presented below ( •

McGrath BA, Bates L, Atkinson D, Moore JA Multidisciplinary guidelines for

the management of tracheostomy and laryngectomy airway emergencies

Anaesthesia 2012; 67(9): 1025-41.

The two algorithms overleaf are reproduced from McGrath BA, Bates L,

Atkinson D, Moore JA Multidisciplinary guidelines for the management of

tracheostomy and laryngectomy airway emergencies Anaesthesia 2012;

67(9): 1025-41, with permission from the Association of Anaesthetists of

Great Britain & Ireland/© John Wiley and Sons, 2012.

Figure 1.4 Emergency tracheostomy management.

Figure 1.5 Emergency laryngectomy management.

• Hypotensive, tachycardic patient with a low GCS indicating poor cerebral

(If the candidate does not identify the diagnosis then ask for the

causes of adrenal insufficiency.)

Primary Addison’s disease:

• Autoimmune adrenalitis

• Haemorrhage secondary and

tertiary causes with a correct explanation)

7) What is the role of the short synacthen test and steroids in severe

You are the doctor on the ICU and have been called to the emergency

department as part of the trauma team where a lady has been admitted

following a road traffic accident She is hypotensive and is about to undergo

a 4-unit blood transfusion prior to going to theatre for urgent surgery.

You are asked by the nurse if you would check the blood before the

transfusion is commenced.

In this scenario the examiner will act as the nurse, and there will be a

manikin arm, with a patient identification (ID) band around the wrist There

will also be four model blood bags with their respective tags, a transfusion

of 2 marks)

http://www.nhsprofessionals.nhs.uk/download/comms/cg4%20-%20blood%20transfusion%20guidelines.pdf.

A 21-year-old newly diagnosed diabetic is admitted to the emergency

department following a night out The patient was believed to have had an

• The primary goal and priority is ketone clearance

• Fluid resuscitation

• Young 18-25 — cerebral oedema.

• Elderly — fluid overload

• Hepatic and renal failure — fluid overload

• Pregnancy — cerebral oedema

9) What rate of insulin administration would you institute and until what

of 2 marks)

•

In a HHS, there is severe dehydration, but due to the high risk of cerebral

oedema the initial fluid replacement is slower compared to DKA;

transfused during resuscitation on the unit In total he received 20 units of

packed red cells; however, when the blood bank checked the transfusion

T ip

Equipment stations, although now less common, are still a

possibility You will be shown a piece of equipment commonly

• intravascular or intracompartmental pressures It is commonly used to

In an IABP monitoring system, arterial pressure changes are converted into

electrical signals by the transducer which are then measured, analysed,

Figure 1.8.

• A catheter or arterial line placed in the artery

• An incompressible rigid or stiff-walled, fluid-filled piece of tubing